Harley Three Weeks on Lev - Thoughts on Dose Still Needed :)

[Laura and Harley (GA)]

Hi everyone,

Harley has been stable since we got home from the vet with only one small flare on Tuesday night. So long as he gets his prednisolone, famotidine, and SubQ fluids I see a semblance of his normal self. He loves boiled chicken which I feed him as treats for shots, tests, medications, etc.

It's been one week or so since Harley stared Lev and so far I've been pleased with the gentle action I'm seeing on the 0.5u starting dose. But the numbers are not ideal. I'm thinking it's time to increase the dose but am looking for suggestions. It's so tempting to bump up to the 1u. That's where my PZI thinking comes into play. ;-) You need to talk me out of it!

BTW I'm prepared to be told I need to test more as we still haven't found his nadir. Mea culpa, the lack of testing is deliberate so we can save both his and my energies for medications and food. This has slightly improved his mood and stress level this last week. Data gathering has just had to take a backseat. Not an ideal situation but about the best I can do at this point. Even with treats and praise at every poke, he's just weary (and wary) of me coming at him with liquids, drugs, needles, fluids, and food.

What does the group think tank think?

 

[Vicky & Gandalf (GA) & Murrlin]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

Yeah, you've gotten 200s every mid cycle test you've done and 300s every preshot. It seems pretty safe to me to go to .75U. That is a 50% increase and well enough to get some results. A couple drops of Lev can make a world of difference.

Glad he's doing better with eating. He no doubt is getting tired of all the fussing. cat_pet_icon

 

[pamela and tigger]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

Agree with Vicky on the dose increase.

I am glad Harley is feeling better. Having a cat that sick is truly stressful so this is good news to hear for both of you!

Your introductory post here has a lot of good information in it regarding Harley's health issues. I would hate to see it get buried. You might want to link it in your profile.

 

[eeraby]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

Mea culpa, the lack of testing is deliberate so we can save both his and my energies for medications and food. This has slightly improved his mood and stress level this last week. Data gathering has just had to take a backseat. Not an ideal situation but about the best I can do at this point. Even with treats and praise at every poke, he's just weary (and wary) of me coming at him with liquids, drugs, needles, fluids, and food.

Hi Laura.. I agree. Harley's unlikely to have a hypo and the less stress from not testing a lot surely is better for him at this point (and for you!).

 

[Laura and Harley (GA)]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

Thank you Vicky and Pamela for your swift replies and dose advice. I'm sorry I did not post a reply last night. I was finishing and e-filing my taxes and in true Murphy's Law fashion - my internet connection was cutting in and out. It came back on just in time so I could e-file at about 11:55 p.m. ohmygod_smile Talk about cutting things close...

I took everyone's advice and raised to 0.75u last night. Harley's PMPS yesterday was 415 - up from his usual but I didn't freak out because I knew he was constipated again. So I added lactulose back into his medication routine and was rewarded with a bouncing baby stool overnight and a lower AMPS.

Last night (before the taxes) he and I sat down on the couch to watch some Cat TV together. He was @-) by the birds and squirrels for about 30 minutes, didn't care so much for the fish.

Pamela - Once again, you are the source of great ideas! I'll add links to Harley's pancreatitis diagnosis post from PZI and his Lev. introduction post in his profile.

BTW Looks like Harley did some grass nibbling overnight! Nothing has come up yet...cross paws antijinx. :mrgreen:

 

[Sheila & Beau GA & Jeddie GA]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

A bit late here, but the increase to .75u is what I would have suggested too.

As for the "extra" testing and saving your energies for the other meds, I do it all at once - meaning, if meds are to be given I start with a BG test, give meds, then a treat. Both Beau and Jeddie get meds on a sid or bid schedule which I combined with PS testing and shot, so that left/leaves mid-cycle testing free of any other "hassles" :roll:

 

[Laura and Harley (GA)]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

Hey Sheila, thanks for weighing in, I appreciate your input. I do currently group Harley's preshot tests, meals and all 2x a day meds between 5:15 and 6 am/pm. The routine goes test, famotidine, treat, break followed by meal, other meds, then Levemir at 6. This frees me up to work 8 hours, come home at lunch time for a +6 test, and then after work do the same routine again at night. I usually do his fluids between 8-9 pm.

I have to say I'm not pleased with the numbers on 0.75u yet. Seems like we've taken a step back. He has been constipated (4/17, 415 PMPS. and yesterday, 424 AMPS) and I know that produces stress which in turn produces higher BGs. But looking at it superficially, we got better numbers on 0.5u. I'm wondering if 0.75u is too much, not enough, or I haven't given it enough time. We're going on our 6th cycle at the new dose tonite. confused_cat

 

[Sheila & Beau GA & Jeddie GA]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

Well, that's a tough one. Today's +6 was a bit better than his +6 on his last day at .5u.

I did just look over his PZI SS to see where the dose was with that and to be honest it looks to me like a really clear case of increasing dose causing increasing numbers. He was doing much better on the .2u doses. That does make me wonder if you are right and the dose increase was the wrong direction to go and that maybe a decrease is needed.

I think that if you drop back to .5u you may see an improvement in a day or so, that would tell you something.

What do you think about doing that? If he wasn't dealing with p-titis, I might be less hesitant about suggesting you try .25u and see what happens. If you started that tonight, you would be in a good place to get a curve in on Sat (assuming you are home). You want to do whatever will get him out of the 300s as soon as possible. Increase enough and that will happen, but at what cost (hypo)?

 

[Vicky & Gandalf (GA) & Murrlin]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

How badly does he stress out at the vet? I'm wondering because that day at the ER, the 11th, when they gave him 1U of R he only dropped to 160 that they caught. He probably was lower than that earlier, because R is very fast, usually in and out of system in 3 hours.

That alone makes me wonder if he just needs more insulin. That use of R looks like a huge drop, but that was on 1 whole unit of R - boy that's a lot! I would have been livid if my vet gave 1U of R on a 449 BG. Gandalf would have gone hypo - he would drop 200 points on .2U of R in 2 hours.

I'm just really concerned that with his concurrent health issues, that has increased his need for insulin. Even though you don't have many mid cycle tests ever one you've gotten is still fairly high and by the protocol would call for a small increase.

I know he did well on low doses of PZI, but he wasn't sick then. Does your vet have an opinion on where to go with dose? During one of Gandalf's flares he had horrible high numbers, but when he first became sick with pancreatitis he had lows from not eating. If Harley's eating OK, then he's probably not going low.

But I see Sheila's point about him maybe needing less and if you go back to .5U and the numbers get back like they were, then that means lesser dose is needed and you would want to lower the dose again.

Does that make sense? It's so early that you don't know until you try something, especially if you have a hunch it might be the right call.

How do you know if he's constipated? Does he strain in the box or just not go that day? Poor guy. He and Gandalf could share stories. :lol:

 

[Laura and Harley (GA)]

Re: Harley 1st Week on Lev - Dose Increase Advice Needed

Hi Vicky and Sheila - Last night was really crazy and I didn't see your posts until after I gave his evening dose. When I did come online, Harley got all jealous of the computer and signaled for some snuggle time which he hasn't done in ages and I just HAD to give in and soak up some kitty love! cat_pet_icon Thanks to your posts, I had lots to think about last night thanks to you two.

I think you are both right, and that is where the quandary lies. Sheila is right that before he got sick, Harley's best dose on ProZinc was about 0.2u. That was when I was feeding him Fancy Feast classic gluten-free flavors that were between 4-5% carbs.

When he got sick the first time, I started switching to Friskies and Fancy Feast Elegant Medleys which had lower fat but had anywhere from 7-13% carbs. Add in the insulin resistance of 5mg per day of prednisolone, and he needed more insulin. But I had no data shooting at those high numbers even without pred. so it was quite a trial and error process of trying to figure out what dose to give him. Sheila is right again in pointing out that more insulin did tend to produce higher numbers. The weekend I shot 2 or even 2.2u into 400+ preshots yielded nothing and it was only when I dropped back that his numbers came down. He didn't hypo on me (thank god) but his poor liver must have been getting a workout. The day we switched to Lev. I was pretty close to his ideal dose - somewhere about 1.4u. Had we not switched I'd have shot 1.4u again that night.

I think Vicky is also right that he probably does need more insulin. I'm feeding higher carb. food and continuing the prednisolone and that does tend to wonkify the #'s. Regarding vet stress, before his illness I'd have said that he doesn't tend to get stressed at the vets. He'd lived 2 months at a vets office recovering from his severe burns before I adopted him and my vet always said how he was the most cooperative cat she'd ever seen. I really think the 449 at the ER vet could be because they held him NPO since midnight and there was a barking dog two cages down. I always free feed him overnight and that results in lower AM preshots. Before I started leaving food out for him, his AM preshots were always higher than his PM preshots. So I really wasn't surprised at the 449. (And we've already covered how LIVID I was that they didn't given him his AM Lev. and wanted to give the R instead. cat(2)_steam )

My gut tells me that either raising or lowering could be the right thing for him. My PZI brain wants to increase and shoot the numbers down. But that has proven to be the wrong choice with him in the past. So to be safe, I backed down to 0.5u this morning figuring that if we don't see any improvement I can always raise again. My vet had said if I didn't see any results on the 0.75u I could go up to the 1u. But I'd rather try lowering first just to make sure we don't miss his correct dose.

 

[Laura and Harley (GA)]

Re: Harley Two Weeks on Lev - Dose Advice Needed

And the award goes to Sheila! drinking24

Todays AMPS was 332, +6=275 and PMPS=361. Movement in the right direction and no reds. This may be the wrong thing to do - please forgive my breaking the rules but I reduced to 0.25 (or as close as my limited vision could get to halfway between the zero line and 0.5) tonight. Raising didn't work, let's see what lowering will do. :mrgreen:

 

[Vicky & Gandalf (GA) & Murrlin]

Re: Harley Two Weeks on Lev - Dose Advice Needed

Laura, Harley is the only winner here!

Seriously, it gets to the point in this game where you have to make a call based on gut feeling sometime. You're doing that, and will go by what the results tell you. That's the way we'd like to see everyone do it, it's the best way you learn what works for your cat. ECID and all that.

Very proud of you for making that call. There are rules and then there's ECID. Don't feel like you broke anything.

When you do break something, we'll send you the bill.

 

[Laura and Harley (GA)]

Re: Harley Three Weeks on Lev - Thoughts on Dose Still Neede

Hi everyone, Rather than start a new thread, I thought I'd keep the old one going for the sake of posterity.

I've not been online much as most of my free time is spent with Harley and also my civvie, Princess, who is very traumatized about all the kitty nursing activity. Harley has been holding his won, eating, peeing, pooping (thanks to lactulose) and having both good days and bad. There have been two vet visits, bloodwork, 2 smaller flares - either the pancreas of IBD. Yes, based on his most recent blood work on 4/20 when we ran a fasting GI panel, he's got probable IBD. Cobalmin was low, folate very normal and TLI very normal. So I started weekly B12 injections last Wednesday. His spec fPL was reduced down to 6.1 from 40 which is still high and signifies pancreatitis but perhaps not nearly as bad as before. His liver values, ALKP, ALT, AST and GGT are all elevated so once again Pamela called it - probable triaditis. My boy has all bases loaded and is going for the grand slam home run! Looking back, this may explain his increased PTT - the ER vet told me that the clotting factors which make up PTT are manufactured in the liver and a clotting disorder could be a symptom of underlying liver disease. So maybe the Anzemet wasn't to blame after all...

Other than the B12 our medication routine hasn't changed. I asked about what we could do for the liver and my vet mentions some things but didn't seem in a hurry to have me start anything. I just ordered some Denamarin and will try to see if I can get Harley to take it. (Oh this is going to be fun...)

Regarding the insulin, I didn't stay long at 0.25 - chalk it up to my impatience but it just didn't seem to be doing much. So I've held 0.5u for 10 days and got a sort-of curve in yesterday. I'd once again appreciate everyone's thoughts on where to go from here.

My vet doesn't want me to make any changes right now so as to not upset the liver and also doesn't know what to make of the above. I see her point, but his continued bouncing isn't helping the liver either.

Any thoughts or advice would be greatly appreciated. And if I'm breaking any rules - send the bills to Harley Davidson, Inc. :mrgreen:

 

[pamela and tigger]

Re: Harley Three Weeks on Lev - Thoughts on Dose Still Neede

Hi everyone, Rather than start a new thread, I thought I'd keep the old one going for the sake of posterity.

I've not been online much as most of my free time is spent with Harley and also my civvie, Princess, who is very traumatized about all the kitty nursing activity. Harley has been holding his won, eating, peeing, pooping (thanks to lactulose) and having both good days and bad. There have been two vet visits, bloodwork, 2 smaller flares - either the pancreas of IBD. Yes, based on his most recent blood work on 4/20 when we ran a fasting GI panel, he's got probable IBD. Cobalmin was low, folate very normal and TLI very normal. So I started weekly B12 injections last Wednesday. His spec fPL was reduced down to 6.1 from 40 which is still high and signifies pancreatitis but perhaps not nearly as bad as before. His liver values, ALKP, ALT, AST and GGT are all elevated so once again Pamela called it - probable triaditis. My boy has all bases loaded and is going for the grand slam home run! Looking back, this may explain his increased PTT - the ER vet told me that the clotting factors which make up PTT are manufactured in the liver and a clotting disorder could be a symptom of underlying liver disease. So maybe the Anzemet wasn't to blame after all...

Other than the B12 our medication routine hasn't changed. I asked about what we could do for the liver and my vet mentions some things but didn't seem in a hurry to have me start anything. I just ordered some Denamarin and will try to see if I can get Harley to take it. (Oh this is going to be fun...)

Regarding the insulin, I didn't stay long at 0.25 - chalk it up to my impatience but it just didn't seem to be doing much. So I've held 0.5u for 10 days and got a sort-of curve in yesterday. I'd once again appreciate everyone's thoughts on where to go from here.

My vet doesn't want me to make any changes right now so as to not upset the liver and also doesn't know what to make of the above. I see her point, but his continued bouncing isn't helping the liver either.

Any thoughts or advice would be greatly appreciated. And if I'm breaking any rules - send the bills to Harley Davidson, Inc. :mrgreen:

Laura, so nice to hear from you and an update on how Harley is doing. So he is named after Harley Davidson? I never made the connection, LOL!

The Triaditis diagnosis at least lets you know what you are dealing with. From a long time member and a very knowledgeable vet tech, Jess (& Earl), "the definition is inflammation of the pancreas and liver triggered by IBD. So the IBD is the founding problem and is the one that is treated." She gives a great write up on this condition on the old FDMB board...read down a couple of posts and Dr. Lisa also weighs in:

Jess on Triaditis

Will Harley take the Denmarin in a pill pocket? That is the only way I could get Tigger to take it. Worked successfully for many years.

Also ask your vet about Ursodial (Actigall). This can be compounded and just added to his food. One of the things that really helped Tigger to gradually recover and generally just feel better overall.

http://www.veterinarypartner.com/Content.plx?P=A&A=549&S=0&EVetID=0

To clarify though, I am not an expert on this by any means. It is only that when Tigger was diagnosed with this condition that I had to become more knowledgeable about it. Just like a lot of us have to do when our kitties become sick with something and we want to take more control over the situation - we learn as much as we can so that we can try to understand. The same as what you are doing with Harley now, and the same as you have done in the past.

I am way late for dinner so will let others address the numbers but will look in later to see if I can add anything.

P.S. just curious though, what are his liver values?

 

[Laura and Harley (GA)]

Re: Harley Three Weeks on Lev - Thoughts on Dose Still Neede

Laura, so nice to hear from you and an update on how Harley is doing. So he is named after Harley Davidson? I never made the connection, LOL!

LOL, yeah, they send a monthly stipend for his vet bills. In my dreams!!!!

The Triaditis diagnosis at least lets you know what you are dealing with. From a long time member and a very knowledgeable vet tech, Jess (& Earl), "the definition is inflammation of the pancreas and liver triggered by IBD. So the IBD is the founding problem and is the one that is treated." She gives a great write up on this condition on the old FDMB board...read down a couple of posts and Dr. Lisa also weighs in:

Jess on Triaditis

Thanks for the great write up! The wacky thing is that if Harley has IBD it might be the constipating kind. He only gets a little bit of of softer poo right before/during a flare. If I wasn't examining his stool daily, I'd miss it completely. Otherwise he's mostly constipated.

Will Harley take the Denmarin in a pill pocket? That is the only way I could get Tigger to take it. Worked successfully for many years.

This will be a challenge. I've been unsuccessful at pilling him so far. His current meds. are 2 shots, 2 liquids that HAVE to taste yummy or else he won't let me put them in his mouth, and 1 transdermal. But if hes going to get better I have to try.

Also ask your vet about Ursodial (Actigall). This can be compounded and just added to his food. One of the things that really helped Tigger to gradually recover and generally just feel better overall.

http://www.veterinarypartner.com/Content.plx?P=A&A=549&S=0&EVetID=0

I did, as you'd mentioned it in a previous post, and she's never heard of it being used for cats. Said she'd look it up which means I have to remind her. :roll:

To clarify though, I am not an expert on this by any means. It is only that when Tigger was diagnosed with this condition that I had to become more knowledgeable about it. Just like a lot of us have to do when our kitties become sick with something and we want to take more control over the situation - we learn as much as we can so that we can try to understand. The same as what you are doing with Harley now, and the same as you have done in the past.

I am way late for dinner so will let others address the numbers but will look in later to see if I can add anything.

P.S. just curious though, what are his liver values?

In my opinion you are more of an expert than 3 out of the 5 vets that I've met in the past 2 months!!! Dr. Pamela when are you going for your DVM?

Let's see GI lab results are:

ALKP 269 (range 0-62)
ALT 169 (range 20-100)
AST 46 (range 5-55) my bad, this one is normal after all
GGT 10 (range 0-6)

spec fPL 6.1
Cobalmin 256 (range 276-1425)
Folate 18 (range 8.9-19.9)
TLI 18.4 (range 12-82)

Funky CBC results:

Eos 18% (range 2-12) somewhat high
ABS Eos 2088 (range 0-1500) this is way high
Platelets 98 (range 170-600)

Since the Eos are so out of whack I asked about testing for parasites. She didn't seem to think it was necessary because it's rare for an indoor cat to get parasites. But I ran over a fecal sample anyway and she sent it to IDEXX for centrifugation. Nothing found. I'm thinking about asking for a toxoplasmosis test just to be sure. He'd tested LIV and leukemia negative in 2007. I guess that leaves an allergic reaction to something (diet, environment) or just good old inflamation. The funny thing is that his Eos weren't elevated on the last bloodwork on 4/1 - the day right after his severest IBD/p-flare to date. Liver values were normal that day as well. All this has happened since 4/1. :cry:

 

[Vicky & Gandalf (GA) & Murrlin]

Re: Harley Three Weeks on Lev - Thoughts on Dose Still Neede

Glad to hear you have a direction with Harley. My vet wants Gandalf to take metronidazole for IBD. Has your vet discussed that medication with you? It targets the intestines apparently. It is a bitter pill, literally, but can be compounded. If controlling the IBD would help, please ask about it.

As for Lev, it just looks like he needs more, he's not bouncing too badly. I see you dropped back form the .75U dose. Was that because he only had higher numbers at that dose? That is odd.

His numbers really aren't too bad with all he has going on. I think they may be the best you can ask for right now. I don't think he has much liver action from rebound on those numbers, so that's a good thing.

If you raise the dose again and he has higher numbers, that may mean it's too much, but I think it's worth a try to see if .75U can get him below 200.

Bless you for doing everything you can for Harley! He's one lucky biker dude!

 

[Laura and Harley (GA)]

Re: Harley Three Weeks on Lev - Thoughts on Dose Still Neede

Glad to hear you have a direction with Harley. My vet wants Gandalf to take metronidazole for IBD. Has your vet discussed that medication with you? It targets the intestines apparently. It is a bitter pill, literally, but can be compounded. If controlling the IBD would help, please ask about it.

I did ask my vet about Flagyl/metronidazole and she said it's very bitter and even compounded he'd probably taste it. When I tried cyproheptadine and ondansetron compounded he frothed, foamed gagged and vomited them up. When I tried pills, the same thing only he developed a food aversion to the duck and pea pill pockets I'd used to coat the pills. Now all I have to do is pass a plain pill pocket under his nose and he starts to foam. We both know I needs the A/B, we're just reluctant to use it for fear he'll stop eating again.

As for Lev, it just looks like he needs more, he's not bouncing too badly. I see you dropped back form the .75U dose. Was that because he only had higher numbers at that dose? That is odd.

Yes, I dropped back to 0.5u not because of the red preshots but more because the midcycle #'s I was getting were pinks. The #'s seemed better on 0.5u. Granted I didn't hold 0.75u for as long nor did I get a curve.

From what I've seen, Harley is a spot on example of llkka's posts on how the body reacts to higher numbers as the new normal and he reacts unfavorably to numbers that he does not perceive as "normal." This especially includes drops that for him are too steep. We may not regard a drop from 350 to 200 as too much but if he's not used to 200 his body over-reacts. When we were shooting micro-doses on PZ I had a hard time convincing people that he really was frantic if he went down below 80. Though not technically hypos, he was reacting to 70s and 60s as though they were. So in a way I'm not surprised that if he were dropping lower on 0.75u he'd bounce more because his body is trying to protect itself.

His numbers really aren't too bad with all he has going on. I think they may be the best you can ask for right now. I don't think he has much liver action from rebound on those numbers, so that's a good thing.

If you raise the dose again and he has higher numbers, that may mean it's too much, but I think it's worth a try to see if .75U can get him below 200.

These are pretty nice #'s for a mere 0.5u. :mrgreen: Would a raise to 0.6u be too small? If his numbers improve then we'll know up is the right way to go. Wondering if maybe his body just didn't like the 50% dose increase...

Bless you for doing everything you can for Harley! He's one lucky biker dude!

Thank you Vicky, I couldn't do what I do for him without the support of all of you here at FMDB! I wish I could say this will have a happy outcome. It's so easy to get discouraged. I'm trying to relax and take one day at a time and enjoy some quality time with Harley and my civvie Princess. So sad, she's become top kitty in the pecking order now and that never used to be that way. Good for her, but shows how sick Harley is feeling. OK, I gotta stop now before I get really morose.

 

[Laura and Harley (GA)]

Re: Harley Three Weeks on Lev - Thoughts on Dose Still Neede

Quick update, I just talked to my second vet and he agrees with starting the Denamarin. He said that typically he sees elevated ALKP, AST with fatty liver but not GGT. He typically sees GGT elevated in cases of hepatitis. He wants me to monitor Harley's temperature and if he's running a fever, we will start an A/B if not, wait and see what the B12 and Denamarin do for him.

Guess I'll be watching YouTube videos on how to take a hissing, spitting, snarling fighting feline's temperate. And that's with the kitty burrito. LOL